PROGRESS REPORT 2013-2015

IMPROVE ACCESS
TO SANITATION

PROGRESS REPORT 2013-2015

Results for children in Pakistan
IMPROVE ACCESS TO SANITATION

Copyright UNICEF Pakistan

Printed in July 2015
Editing Sarah Nam
Graphic design Giovanna Burinato
Photographs Sami Malik (p. 14), Asad Zaidi (cover page, p. 6, 10, 11, 13, 15)
For more information contact Daniel Timme
Chief of Advocacy and Communication, dtimme@unicef.org

FOREWORD
In recent years, the Government of Pakistan has demonstrated increased commitment to
social sector development, consequently leading to some notable successes. In particular,
the country is celebrating the recent achievement of the Millennium Development Goal
(MDG) for sanitation, halving the proportion of the population without sustainable access to
basic sanitation. Over the past two decades, the government has also made notable strides
in combatting polio, increasing routine immunization and decreasing the number of out-ofschool children.

PROGRESS REPORT 2013-2015

Results for children
in Pakistan

UNICEF, along with its partners, is supporting the Government of Pakistan to achieve the
MDGs and will continue to do so in the post-2015 era. More specifically, UNICEF is providing
support to achieve the following results in Pakistan:
- BIRTH REGISTRATION: Achieve universal birth registration by 2024
- EDUCATE ALL CHILDREN: Provide access to improved education to more than 1.2 million
children in Pakistan by 2017
- ERADICATE POLIO: Eliminate the disease by May 2016
- STOP STUNTING: 1.9 million fewer children with stunted growth and development by
2017
- IMPROVE ACCESS TO SANITATION: 10 million fewer people practising open defecation
by 2017
- DECREASE CHILD DEATHS: Reduce newborn mortality from 55 to 20 live births per
1,000 by 2017, and have 90 percent fully immunized children (aged 12-23 months) by 2017
These progress reports take a deeper look into these issues, including the latest data and how
government interventions have positively impacted children and communities in Pakistan.
These reports also present key challenges, recent research, knowledge and evaluations, and
strategic direction for the future.
Through these reports, we seek to foster productive collaboration, demonstrate the collective
contribution of UNICEF and its partners, and reassert our commitment to the Convention on
the Rights of the Child.

BIRTH REGISTRATION
EDUCATE ALL CHILDREN
ERADICATE POLIO

STOP STUNTING
IMPROVE ACCESS TO SANITATION
DECREASE CHILD DEATHS

Angela Kearney
UNICEF Representative in Pakistan

OVERVIEW
A HUGE SUCCESS
Pakistan reaches the MDG goal for improved sanitation in 2015
By halving the proportion of the population without sustainable access to basic
sanitation from 76 percent in 1990 to 36 percent in 2015, Pakistan has successfully
reached the Millennium Development Goal1 for sanitation.
This means that 64 percent of Pakistanis are now using an improved sanitation facility2
- an incredible achievement. Pakistan is one of only 95 countries in the world to meet
the global targets for sanitation.

Ending open defecation

The practice of open defecation detrimentally affects childrens lives, making them more
susceptible to stunting and exposing them to the risk of diarrhoea, polio and other easily
preventable diseases. It also poses safety concerns, especially for women and girls.
Overall, the number of open defecators in Pakistan has reduced from 46 million to 25 million
in the past ten years3 a huge contributor to the countrys recent successes achieving the
sanitation MDG. Ending open defecation will continue to be a crucial step to ensuring
sustainable access to improved sanitation in Pakistan.
However, these tremendous improvements hide large disparities that still exist the majority
of people who have stopped practicing open defecation since 2005 are primarily among the
richest or urban populations.
The remaining 25 million people (or 13 percent of the population) still practising open
defecation in Pakistan are largely residing in poor rural dwellings and insecure urban informal
settlements, making them the most difficult to reach. Open defecation is still socially accepted
and practiced in many communities.
UNICEF strongly supports the Pakistan Approach to Total Sanitation (PATS), the Government
of Pakistan-led approach, which has proven to be successful in forming and promoting the
new No Open Defecation mind-set. This progress report summarises trends, projections,
innovative approaches, recent evaluations and research relevant to the elimination of open
defecation in Pakistan.

IMPROVE ACCESS
TO SANITATION

GLOBAL
TARGET

UNICEF PAKISTAN
TARGET

End open defecation by 2025

10 million fewer individuals practising

open defecation by 2017.
An additional 15 million fewer individuals
practising open defecation by 2025,
ending open defecation in Pakistan.

Inadequate sanitation in Pakistan costs the country

PKR 343.7 billion every year equal to 3.94 percent
of GDP4.
In Pakistan, 110 children under the age of five dies every day from diarrheal-related
disease, often attributable to poor sanitation.5

HOW UNICEF WILL HELP ACHIEVE RESULTS

Since 2011, after major floods devastated much of the country, UNICEF has been supporting
the government to end open defecation and improve access to sanitation. Following the
floods, the Pakistan Approach to Total Sanitation (PATS) was developed as a country specific
strategy to scale up rural sanitation programmes.

It is unfortunate that the lack of sanitation

facilities is one of the major causes of the
high child mortality rate in Pakistan, despite of
the fact that cleanliness is declared half faith in Islam.
Mr. Mamnoon Hussain
H.E. Honourable President of the Islamic Republic of Pakistan

PROGRESS REPORT 2013-2015 IMPROVE ACCESS TO SANITATION

To date, UNICEFs work has included implementing large scale sanitation programmes,
advocating for policy change and providing strategic advice, improving institutional and
stakeholders coordination, developing public private partnerships, advocating for increased
allocation of public funds and improving sector financing all vital activities that will help
achieve and sustain the target results.
Since 2011, more than 11 million fewer people live in Open Defecation Free (ODF) villages as
a result of the PATS programmes of which 6.5 million can be directly attributed to UNICEF
funded programmes.

PROGRESS REPORT 2013-2015 IMPROVE ACCESS TO SANITATION

DATA PROFILE

2025 ODF PAKISTAN

2017
15 MILLION FEWER OPEN DEFECATORS

Trends in reduction of open defecation in the richest and poorest wealth quintiles6
The majority of the 25 million people not using a toilet in Pakistan live in poor rural households
or insecure urban informal settlements. This makes them the most difficult to reach an
equity issue which requires focused strategies and more effort in years to come.

Population practising open defecation

Key indicator: ODF Status achieved through family/individual

action to build latrines, adopted by the whole community.

Core outcome: Changing societal and individual expectations

about open defecation

OUTCOMES AND INDICATORS

Collective
and individual
Action

New
behavioural
expectations

OD
(cultural
practice)

PROGRESS REPORT 2013-2015 IMPROVE ACCESS TO SANITATION

100%

100

100

100

94
86

80%
72
60%

40%

42

31
20%

0%

45

60

38

Richest
Poorest

27
21

1995

2012

IndiaN

1995 2012
aNepal

1995

2012

Pakistan

1995

2012

Bangladesh

Data source: WHO/UNICEF Joint Monitoring Program (JMP) for Water Supply and Sanitation. 25 Years Progress on
Sanitation and Drinking Water. 2015 Update and MDG Assessment.

Current trends will be difficult to maintain

Core Principles of PATS
adopted throughout the
process

Stabilizing/
normalizing
the Social
Norm

Closing equity gaps in sanitation will remain a challenge. The graph below highlights the
inequities in access to sanitation between the poorest and wealthiest quintiles in four
countries in South Asia, including Pakistan.

Reinforcments
of Social Norm
(from fragile
to stable)
ODF
New
Social
Norm
(fragile)
Change in
collective/
individual
preferences
Awareness
Recognition

Preexisting
normative
beliefs and
attitudes

PROCESS OF CHANGE: ACHIEVING A NEW SOCIAL NORM FOR ODF

Promotion

- Recognition / Certification / Celebration

Intervention

- Identification of potential communities / regions

- Pre-triggering / Triggering / Advice / Hygiene

Pre-intervention
enabling
environment
Training/Resources

PATS Implementation Framework

INPUTS

Post-intervention
Follow-up support
Advice, Monitoring
of usage and quality

2015
10 MILLION FEWER OPEN DEFECATORS

If current trends are maintained, Pakistan will reduce the number of open defecators by
10 million by 2017. However, maintaining the current trend will be challenging as we start
targeting the hardest-to-reach populations. To ensure that people from the poorest families
start using a toilet, we need more resources to implement programmes with a strong focus on
equity. This means increasing investment in sanitation.
Investment is also critical to ensure that people continue to use toilets. This two-pronged
approach focused on 1) reaching the unreached and 2) sustaining the social norm to ensure
all gains are sustainable. Government sanitation programmes will also need to include urban
informal settlements to reach the last 13 percent by the year 2025.

PROGRESS REPORT 2013-2015 IMPROVE ACCESS TO SANITATION

Open defecation in Pakistan - trends

60

58
54
48

50

41

million

40
30

25

20

15

10
0

0
1990

2000

2008

2012 2014

2017

2025

Data source: WHO/UNICEF Joint Monitoring Program (JMP) for Water Supply and Sanitation. 25 Years Progress on
Sanitation and Drinking Water. 2015 Update and MDG Assessment.

ACCELERATING CHANGE IN PAKISTAN

IMPORTANT ACTIONS
Supporting national action on sanitation
In 2015, UNICEF supported the Ministry of Climate Change to organize the second Pakistan
Conference on Sanitation (PACOSAN). The event drew together more than 500 Ministers,
Parliamentarians, senior Government officials, private sector and development partners to
discuss the issue of sanitation at the national level.
The impact of the event has been immense, as decision makers and influencers have continued
to act on their commitment to eradicate open defecation in Pakistan. Most significantly, the
national government has included open defecation free targets into the Government of
Pakistans Vision for 2025. At the provincial level, the Punjab Government has allocated
PKR 400 million of public funding for sanitation, and the Sindh Government is developing a
combined Water, Sanitation and Hygiene and Nutrition programme to reduce stunting in the
province.

Subsidies for extremely vulnerable families

In UNICEF-funded programmes across Pakistan, extremely vulnerable families are being
given subsidies in the form of sanitation vouchers. Identified by the communities themselves,
the families use these vouchers to acquire materials to construct latrines. These latrines also
serve as demonstration latrines, showing other community members acceptable standards
and design.
In the coming year, UNICEF will continue to research and model the use of subsidies for the
most vulnerable, including in the context of populations affected by disasters and urban slum
populations. This will also help to further elaborate strategies for the hardest-to-reach people.

10

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11

Using the power of mass media to end open defecation

UNICEF is providing major support to sector partners, the Government and political leaders
to launch a mass awareness campaign through online and print media to promote No Open
Defecation in both rural and urban communities. The campaign aims to reach 15 million
people over the next three years and will leverage the influence of celebrities, the private
sector and the media.

LOOKING FORWARD
As the Government of Pakistan and partners celebrate the achievement of the sanitation MDG
and the reduction in the number of people who defecate in the open, the ultimate objective of
ending the practice of open defecation by 2025 must be kept in view.
Substantially more progress is needed to eliminate open defecation over the next 10 years.
Based on the considerable progress made to date, eradicating open defecation in Pakistan by
2025 is possible.

EQUITY
Only 64 percent of Pakistans population uses improved sanitation, with a wide disparity
between urban (83%) and rural areas (51%).
Wealth quintiles: Only 13 percent (8 percent rural, 65 percent urban) of the poorest have
access to improved sanitation compared to 80 percent (68 percent rural, 85 percent urban)
among the richest.

UNICEF will continue to integrate research and evidence into its programmes and policy
advocacy, focusing on the poorest and hardest-to-reach communities. Innovations will be
sought in all areas, including technical design, financing, incentives, demand generation and
supply chain improvement. We will also seek to strengthen partnerships with the private
sector, academia and other development partners to reach this common goal.

Rural versus urban: There is a very high disparity between people who openly defecated in
rural (21%) and urban (1%) areas.

CHALLENGES

From 1995 to 2010, the progress in increased access of the poorest to improved sanitation in
rural areas has only been 6 percent (from 5% to 11%) whereas for the rich and richest this has
been significant, 43 percent and 44 percent respectively7.
100

Coverage %

80

1
9
7

8
20

14

49

67

13

21

18

A key challenge for the next 10 years will be to close existing inequity gaps, particularly
between urban and rural communities and between the richest and poorest.
UNICEF is committed to supporting the Government and people of Pakistan to meet this
challenge.
While continuing to support programme implementation, UNICEF will also focus on
strengthening governance structures surrounding sanitation, water and hygiene, with a
specific emphasis on monitoring and sustainability.

60

10
83
40

25

66

64

20

27

1
5
1990

2015

Urban
Open defecation

51

2
24

1990

2015

Rural
Other unimproved

1990

2015

Total
Shared facilities

Improved facilities

Data source: Government of Pakistan, Pakistan Demographic Health Survey 2012-2103.

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RESEARCH, KNOWLEDGE, EVALUATION

An evaluation of UNICEFs large-scale rural sanitation programme based on the Pakistan
Approach to Total Sanitation: Results and findings from evaluations of Rural Sanitation in
Flood Affected Areas (RuSFAD) Phase III in 2013, and the Sanitation Programme at Scale
(SPSP) in Pakistan Phase I in 2014.

REAL LIVES, REAL CHANGE

Building household toilets in rural Pakistan

United Nations Childrens Fund 2015, Mapping of Inequities in Basic Water Supply and
Sanitation Services in Pakistan: A presentation of provincial and district analysis of access
to water supply and sanitation with regards to the disparities that exist based on wealth or
geography.
Learning Action and Learning (LAL) Research in Menstrual Hygiene Management 2014: A
study of the perceptions, myths and understanding of adolescent girls surrounding menstrual
hygiene and its management in Pakistan.

In 2014, Mai Sayani became the first woman from her village to build a toilet in her home.
Mai, who lives in the Tangwani village in the Kashmore District of Sindh, Pakistan, is a widow
and mother of four.
All our lives we have been defecating in the fields far from our houses.
Women in our community used to manage their diet in such a way that the need to defecate
would not arise during the day, as they didnt want to be seen defecating in the fields. They
preferred going after sunset, though it was more insecure.
The community workers in our village introduced us to the concept of improved sanitation
and its importance. With their help, I and my daughters built a toilet in our house. It cost us
only 5,000 rupees (USD 50). The idea is common now and all houses in our village have toilets.

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Endnotes
World Health Organization and United Nations Childrens Fund 2015, 25 years of progress on
Sanitation and Drinking Water 2015 Update and MDG Assessment, Joint Monitoring Program
for Water Supply and Sanitation, <www.unicef.org/publications/files/Progress_on_Sanitation_and_
Drinking_Water_2015_Update_.pdf>, accessed July 2015.
2
An improved sanitation facility is defined as one that hygienically separates human excreta from
human contact.
3
World Health Organization and United Nations Childrens Fund 2015, 25 years of progress on
Sanitation and Drinking Water 2015 Update and MDG Assessment, Joint Monitoring Program
for Water Supply and Sanitation, <www.unicef.org/publications/files/Progress_on_Sanitation_and_
Drinking_Water_2015_Update_.pdf>, accessed July 2015.
4
The Water and Sanitation Programme 2012, The Economic Impact of Inadequate Sanitation in Pakistan,
World Bank, <www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2012/04/1
9/000356161_20120419022220/Rendered/PDF/681600WSP0Box30IC00WSP0esi0pakistan.
pdf>, accessed July 2015.
5
United Nations Inter-agency Group for Child Mortality Estimation 2014, Levels & Trends in Child
Mortality: Report 2014, UNICEF, New York. UNICEF analysis based on 2014 provisional estimates
from the World Health Organization and Child Health Epidemiology Reference Group, <www.who.
int/healthinfo/statistics/ChildCOD_method.pdf>, accessed July 2015.
6
World Health Organization and United Nations Childrens Fund 2015, 25 years of progress on
Sanitation and Drinking Water 2015 Update and MDG Assessment, Joint Monitoring Program
for Water Supply and Sanitation, <www.unicef.org/publications/files/Progress_on_Sanitation_and_
Drinking_Water_2015_Update_.pdf>, accessed July 2015.
7
Ibid.
1

The maps in this publication are stylized and not to scale. They do not reflect a position by UNICEF on
the legal status of any country or territory or the delimitation of any frontiers. The dotted line between
Jammu and Kashmir represents approximately the Line of Control agreed upon by India and Pakistan.
The final status of Jammu and Kashmir has not yet been agreed upon by the Parties.

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